What is the next step in evaluating a 25-year-old patient with right scapular (shoulder blade) pain and neck pain?

Differential Diagnosis and Next Steps for 25-Year-Old with Right Shoulder Blade and Neck Pain

For a 25-year-old patient with right scapular and neck pain, the next step should be cervical spine radiographs to rule out structural abnormalities, followed by a thorough assessment for shoulder impingement syndrome, which can commonly present as referred neck pain. 1, 2

Initial Assessment Algorithm

1. Screen for Red Flags:

   • Trauma history
   • Malignancy history
   • Systemic disease (ankylosing spondylitis, inflammatory arthritis)
   • Suspected infection or IV drug use
   • Intractable pain despite therapy
   • Tenderness over vertebral body
   • Neurological deficits 1

2. Physical Examination:

   • Cervical range of motion testing (most commonly used method - 95.3% of practitioners) 3
   • Neurological examination (78.1% of practitioners use this) 3
   • Shoulder impingement tests:
     • Neer's test
     • Hawkins-Kennedy test
     • Pain with forward elevation above 90° 2
   • Scapular positioning assessment (look for downward rotation syndrome) 4

Imaging Recommendations

If No Red Flags Present:

• Initial imaging: Cervical spine radiographs 1
• Radiographs can diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis 1

If Red Flags Present or Initial Treatment Fails:

• MRI cervical spine without contrast (preferred for suspected nerve root compression) 1
• Shoulder ultrasound or MRI if shoulder pathology is suspected 5

Key Diagnostic Considerations

Cervical Radiculopathy

• Look for sensorimotor deficits in nerve root distribution
• Pain radiating to arm with sensory/motor loss in affected nerve distribution 1

Shoulder Impingement Presenting as Neck Pain

• Often overlooked diagnosis - 30 of 34 patients with neck pain in one study had immediate relief after subacromial injection 2
• Characteristic finding: pain referred to neck with positive impingement sign 2
• Consider this diagnosis when patient presents with pain near superomedial aspect of scapula 2

Scapular Downward Rotation Syndrome

• Common cause of shoulder and neck pain in young adults
• Assess scapular positioning and axioscapular muscle imbalance 4, 6

Treatment Considerations

If shoulder impingement is identified:

• Subacromial corticosteroid injection can provide diagnostic confirmation and therapeutic benefit 5, 2
• Avoidance of impingement position (forward elevation of arm above 90°) 2
• Scapular upward rotation exercises with or without visual feedback 4

If cervical pathology is identified:

• NSAIDs for pain control (lowest effective dose) 5
• Physical therapy with phased rehabilitation approach 5
• Activity modification to avoid painful movements 5

Common Pitfalls to Avoid

1. Missing shoulder pathology: Neck pain can be referred from shoulder impingement - always examine the shoulder even when the primary complaint is neck pain 2, 3

2. Rushing to advanced imaging: MRI should not be the first-line imaging modality for uncomplicated neck pain without red flags 1

3. Incomplete examination: Failure to assess both the cervical spine and shoulder complex can lead to missed diagnoses 3, 7

4. Overlooking scapular positioning: Scapular dyskinesis and downward rotation syndrome are often overlooked causes of neck and shoulder pain 4, 6

By following this structured approach, you can efficiently diagnose the cause of right shoulder blade and neck pain in this young patient and initiate appropriate treatment to improve morbidity, mortality, and quality of life outcomes.